A Large Pleural Effusion in a Previously Healthy Woman

1
A Large Pleural Effusion in a Previously Healthy
Woman

• Douglas B. White, MD
• Pulmonary Conference
• December 10, 2002

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Case Presentation

• The patient is a 52 year-old woman with
  hypothyroidism transferred to UCSF for further
  evaluation of a pleural effusion. She was in her
  USOH until 10 days PTA when, while skiing at Lake
  Tahoe, she noted profound fatigue. Shortly
  thereafter, she developed chills, subjective
  fever and SOB with climbing one flight of stairs.
  
• Her symptoms persisted and she presented to an
  OSH for further evaluation. She was found to have
  a white-out of her left hemithorax. Three
  liters of exudative serosanguinous pleural fluid
  were drained via thoracentesis and the patient
  felt better after 2 days of treatment with
  ciprofloxacin. On the third hospital day, she
  noted increasing SOB and a CXR revealed
  reaccumulation of the effusion.

3
Case Presentation

• A chest tube was placed and the patient was
  transferred to UCSF for further evaluation.
• The patient denies recent illness, weight loss,
  night sweats, and productive cough. One month
  ago, the patient could walk up 10 flights of
  stairs without difficulty.

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Case Presentation

• PMH
• Hyperthyroidism- s/p ablation? hypothyroidism
• MEDICATIONS
• Synthroid
• Ciprofloxacin
• NKDA

5
Case Presentation

• Social History
• Emigrated from Russia in 1996
• Works as a child care provider
• 20 pack-year smoking history still smoking
• Moderated vodka consumption
• No drug use

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Case Presentation

• Physical Examination
• 38.8 120/70 80 12 96 RA
• Gen well appearing woman in NAD
• HEENT no LAD or thyromegaly
• LUNGS rales at L base no wheezes.
• CV no JVD no rub, murmurs or extra heart sounds
• ABDOMEN benign
• EXT normal joints, no edema, clubbing or rash.
• Neuro nonfocal

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Case Presentation

• Labs
• WBC20 Hct 34 plt 499
• Electrolytes and LFTs normal
• Pleural Fluid ( from OSH)
• Exudative (LD 1820 Tprot4.5)
• WBC 7200 (75 PMNs)
• Glucoselt20
• Amylaselt20
• Gram stain and culture negative
• AFB negative
• Cytology negative x 2

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Case Presentation

• Labs (cont)
• ANA negative
• RF negative
• ESR 98
• Induced sputum AFB smear neg x 2
• PPD negative
• Pleural Fluid (at UCSF)
• Transudate
• WBC 98 (87 PMNs)
• RBC 14,000
• AFB smear negative cytology negative

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Admission Chest X-Ray
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Chest CT 1
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Chest CT 2
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Chest CT 3
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Hospital Course

• Due to persistent evidence of loculation, the
  patient went to the OR on HD3 for decortication.
  A single loculated fluid collection was found
  containing pus. The pleura was noted to be
  diffusely thickened and nodular. Intraoperative
  biopsy revealed malignant mesothelioma and the
  patient underwent left pleurectomy.

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Hospital Course

• Final pathology revealed invasive,
  epithelioid-type malignant pleural mesothelioma.
  (CEA neg, calretinin positive)
• The patient was discharged to home on HD 6 to
  follow up in Oncology clinic regarding
  chemotherapy/XRT.

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Clinical Presentation of Mesothelioma

• Most patients present with dyspnea and
  nonpleuritic chest pain.
• Most have large unilateral pleural effusions.
• 60 have right-sided lesions.
• 5 have bilateral disease on presentation
• 20 have evidence of asbestosis.
• Chest CT pleural thickening/nodularity invasion
  of chest wall, ribs, or mediastinal structures.

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Malignant Mesothelioma
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Malignant Mesothelioma with Invasion
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Diagnosis of Malignant Pleural Mesothelioma (MPM)

• Thoracoscopic Biopsy vs. Needle Pleural Biopsy
  and Pleural Fluid Cytology
• Prospective study of 188 patients diagnosed with
  MPM
• 10-20 pleural biopsies taken from visceral,
  parietal and diaphragmatic pleura. Unclear how
  many specimens taken with needle biopsy.
• Histopathologic Techniques tissue section H E,
  CEA antigen, keratin stain, vimentine, other
  tumor markers and monoclonal staining.
• Diagnosis made by panel decision (French
  National Panel)

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Diagnosis of Malignant Mesothelioma

• Results
• 92 presented with large effusion 7 with
  pleural mass and no effusion
• 26 diagnosed by pleural fluid cytology
• 21 diagnosed by needle biopsy
• 39 diagnosed by fluid cytology needle biopsy
• 98 diagnosed by thoracoscopic biopsy
• 10 had tumor seeding along track of trocar or
  drain (none since initiation of preventive
  radiation therapy at all entry points).

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Diagnosis of Malignant Mesothelioma

• Conclusions
• Thoracoscopic biopsy is a safe an accurate
  diagnostic alternative to pleural fluid cytology
  and needle biopsy.
• Thoracoscopy should be undertaken early to
  prevent repeated thoracentesis/needle biopsy.
• Radiation therapy is necessary after manipulation
  of pleura to prevent tumor seeding.

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Butchart Staging System for Mesothelioma
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Treatment of Malignant Mesothelioma

• Treatment measures, including surgery, radiation
  therapy, chemotherapy, intrapleural therapy, and
  combined-modality therapies, have generally had
  minimal impact on survival.
• Median survival is 6-18 months with therapy, 4-13
  months without therapy.
• Surgical treatment options include pleurectomy
  and extra-pleural pneumonectomy (EPP).
• Radiation therapy for mesothelioma is limited by
  the large treatment volumes required (the entire
  hemithorax), and the radiation sensitivity of the
  surrounding organs.

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Treatment of Localized Mesothelioma

• Objective to identify prognostic variables for
  survival in trimodality treatment of MPM.
• Study Design 183 patients underwent EPP,
  chemotherapy and radiotherapy.
• Findings
• 38 survival at 2 years 15 5-year survival
  (median 19 months)
• Epithelial cell type median survival 26 months
  (plt0.001)
• Negative resection margins median survival 23
  months (p0.02)
• Negative extrapleural nodes med survival 21
  months (p0.004)

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Treatment of Localized Mesothelioma

• Findings (cont)
• 17 (31/183) patients had all 3 positive
  prognostic variables.
• 68 2-year survival 46 5-year survival median
  51 months (p0.01).
• Conclusions
• Multimodality therapy with EPP is feasible is a
  subset of patients with malignant mesothelioma.
• Patients with epithelial-type, margin-negative,
  extrapleural node-negative resection have
  significantly improved survival.

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Summary

• Malignant mesothelioma often presents as a large,
  unilateral pleural effusion.
• The diagnosis can be made by pleural biopsy and
  pleural fluid cytology in roughly half of cases
  and by thoracoscopy in gt95 of cases.
• The prognosis for patients with malignant
  mesothelioma is generally grim, but a subset of
  patients can have significant survival benefit
  with trimodality therapy.

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Selected References

• Antman et al. Natural history and epidemiology of
  malignant mesothelioma. Chest 1993 Apr103(4
  Suppl)373S-376S.
• Sugarbaker et al. Resection margins, extrapleural
  nodal status and cell type determine
  post-operative long-term survival in trimodality
  therapy of MPM. J Thorac Cardiovasc Surg. 1999
  117(1) 54-63.
• Boutin et al. Thoracoscopy in Pleural Malignant
  Mesothelioma A Prospective Study of 188
  Consecutive Patients. Cancer. 199372389-93.
• Senyigit et al. Incidence of Malignant Pleural
  Mesothelioma due to Environmental Asbestos Fiber
  in Southeast Turkey. Respiration. 200067610-14.